Provider Demographics
NPI:1518033158
Name:NEELY, TIA SMITH (MD)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:SMITH
Last Name:NEELY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:SMITH
Other - Last Name:SANDERLIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 117264
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-7264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1935 HOMER RD STE A
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-8802
Practice Address - Country:US
Practice Address - Phone:706-335-9060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-27
Last Update Date:2021-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051379207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA862125982AMedicaid
GA862125982AMedicaid
H52991Medicare UPIN